Wiki Fraud????

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kassimayfield

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I work for an NP who owns a men's clinic. We have an MD come in very rarely. (He sees maybe 5-8 patients a month.) The NP is not in network with most insurance companies and I have been told to bill under the MD for all claims that she is out of network. Also, all claims for the day go under the MD if he is in the office for even 5 minutes and doesn't see any patients. Most of these patients have NEVER seen the MD and yet all of their claims are submitted with his NPI. I'm almost positive that this is fraud. Do you have any documentation to back me up? And how would you go about approaching this? I've already told her that I don't think it's correct and that I don't really feel right about it. She assured me that she "checked into it" and my job is to make sure she is getting paid.

Also, we mainly do testosterone injections. 95% of our claims look like this.99214- 25 modifier, 96372, and J1080 or J1070. Is she misusing the 25 modifier in order to get paid more? If it's a routine injection, shouldn't we leave off the modifier?


IF this is fraudulent, am I required to report it? Can I be held responsible? I'm not certified yet, but take my CPC on the 19th and want to make sure everything is in order.

Thank you in advance for your help!
 
The NP cannot bill using the MD number unless he is in the office at the time of the encounter and has examined the patient in a prior visit with a written plan of care in the chart that the NP is following up on. If the payer does not follow MCare then you need something in writing stating you may use the MD number even when he is not in the building and may have never examined the patient for the same reason.
As far as a visit level and an injection. If the reason for the visit is to receive the injection then you cannot bill a visit level with or without the 25 modifier
 
You should refer to medicare's "incident to" policy. What they are billing is incorrect and is resulting in higher reimbursement than it should be. I would suggest getting a good grasp on the "incident to" policy and trying to explain it to them one more time while providing them this information.
 
Does the documentation fit for a level 4 visit?

In order to bill a 99214 visit, the office visit must meet all of the correct components of History, Exam and Medical Decision Making and this must all be documented for each visit for each patient.

Using a few charts, you can audit for documentation. You can find a tool to help you determine this here: http://www.novitas-solutions.com/webcenter/content/conn/UCM_Repository/uuid/dDocName:00004966

If the link does not work, Google "Novitas Solutions Documentation Worksheet".

The provider may not even realize the risk they are creating and an objective tool may give you the starting point to discuss their documentation. If they are not documenting, it may be because the level of service is not occurring.
 
The original poster had included......
" Also, we mainly do testosterone injections. 95% of our claims look like this.99214- 25 modifier, 96372, and J1080 or J1070. Is she misusing the 25 modifier in order to get paid more? If it's a routine injection, shouldn't we leave off the modifier?"

Basically IF this is all that is done and doesn't not contain the components of the modifier 25 descriptor, then I don't see how the office can be adding an office visit with the modifier? What diagnoses are they using? And yes, by doing so they may be increasing reimbursement, but woe to them when the auditors come knocking at the door"

You be wise to do the research to offer a rebuttal to their billing procedures. It's a tough position to be in when you're so new.
 
Cya

It appears to me that both pieces you indicate above definitely fall into the "waste and abuse" definition. Since you have mentioned it and been told "it is fine, do it anyhow", likely it falls into the "fraud" category, but that depends on the determination of intent, which would need to be made by a higher authority. My suggestion to you would be to locate the CMS documentation on Incident To Billing and the criteria regarding when it is appropriate to append a 25 modifier to bill both an office visit and an injection, put it in writing to "cover your backside" and indicate that neither criteria is being met based on your understanding of these billing rules. Then you must make a decision - continue to do something you disagree with (perhaps while you look for another job), start to bill correctly (risking your employment), set a date upon which you plan to make such a change, etc. You could also consider reporting these activities to all payers that your provider does business with as a whistleblower.

I hope this helps!
Shelly
 
the nurses in our urology office also give the testosterone injections and we do not bill any office visit. She should be billing only the J code along with the administration code. In our practice if a nurse provides an office visit it is only a 99211 and usually they are providing some form of patient teaching hope this helps.
 
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